CAA Rx Reporting

August 26, 2022


The Consolidated Appropriations Act, 2021 (CAA) requires plans and issuers to submit information regarding the costs of prescription drugs and other health care services each year to the Center for Medicare & Medicaid Services (CMS). The rule generally applies to group health plans and health insurance issuers offering group or individual health insurance coverage. The term ‘‘group health plan’’ encompasses both self-funded and insured health plan, including employer-sponsored group health plans subject to ERISA, non-federal governmental plans (such as plans sponsored by states and local governments) subject to the Public Health Services (PHS) Act, and church plans subject to the Internal Revenue Code. Individual health insurance coverage includes student health insurance coverage. Plans consisting only of HIPAA excepted benefits do not have to comply.

December 27, 2022 is the filing deadline to report information for calendar years, 2020 and 2021. Information for 2022 and beyond will be required to be filed by June 1 of the following year. The Departments intend to use this information to issue public reports on prescription drug pricing costs and trends beginning in 2023.

The required information includes the following:

           • The 50 costliest prescription drugs by total annual spending;

           • The 50 prescription drugs with the greatest increase in plan or coverage expenditures from the previous year;

           • Prescription drug rebates, fees, and other remuneration paid by drug manufacturers to the plan or issuer in each therapeutic class of drugs, as well as for each of the 25 drugs that        
             yielded the highest amount of rebates; and

           • The impact of prescription drug rebates, fees, and other remuneration on premiums and out-of-pocket costs;

           • General information regarding the plan or coverage;

           • Enrollment and premium information, including average monthly premiums paid by employees versus employers;

           • Total healthcare spending, broken down by type of cost (hospital care; primary care; specialty care; prescription drugs; and other medical costs, including wellness services), including
             prescription drug spending by enrollees versus employers and issuers;

For self-funded group health plans, most of the information should be available from a plan’s PBM, yet some information may only be available from the plan sponsor (such as premiums) and the TPA (such as paid healthcare services). Plans should coordinate an approach among the parties to ensure the full CAA reporting requirements are met. Please note that the guidance on reporting clearly states that more than one entity can report on behalf of one health plan, as long as the entities do not overlap in terms of which requirements they report.

To assess your plan’s readiness or discussions thus far that you’ve had with your PBM partner, we are asking that you please answer the following questions. Please respond back to this message so that we may confirm how your plan reporting will be handled.

           • Has the Plan confirmed that the PBM will submit the prescription drug portion of the data to CMS, on the Plan’s behalf?

           • Does the Plan want WebTPA to submit the healthcare spending data directly to CMS, on the Plan’s behalf?

           • Does the Plan want WebTPA to provide the healthcare spending data to its PBM to allow the PBM to file all information (prescription and healthcare), on the Plan’s behalf?

For more information, the CMS Reporting Instructions and other details can be found here